Provider Demographics
NPI:1336496843
Name:HERRON, HEATHER
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19123 180TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-6439
Mailing Address - Country:US
Mailing Address - Phone:386-590-7283
Mailing Address - Fax:
Practice Address - Street 1:19123 180TH ST
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-6439
Practice Address - Country:US
Practice Address - Phone:386-590-7283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant